Carbapenem‐resistant A cinetobacter baumannii acquired before liver transplantation: Impact on recipient outcomes

Abstract

Infection with carbapenem-resistant Acinetobacter baumannii (CRAB) after liver transplantation (LT) is associated with high mortality. This study aimed to identify risk factors for post-LT CRAB infection, as well as to evaluate the impact of pre-LT CRAB acquisition on the incidence of post-LT CRAB infection. This was a prospective cohort study of all patients undergoing LT at our facility between October 2009 and October 2011. Surveillance cultures (SCs) were collected immediately before LT and weekly thereafter, until discharge. We analyzed 196 patients who were submitted to 222 LTs. CRAB was identified in 105 (53.6%); 24 (22.9%) of these patients were found to have acquired CRAB before LT, and 85 (81.0%) tested positive on SCs. Post-LT CRAB infection occurred in 56 (28.6%), the most common site being the surgical wound. Multivariate analysis showed that the risk factors for developing CRAB infection were prolonged cold ischemia, post-LT dialysis, LT due to fulminant hepatitis, and pre-LT CRAB acquisition with pre-LT CRAB acquisition showing a considerable trend toward significance (P = 0.06). Among the recipients with CRAB infection, 60-day mortality was 46.4%, significantly higher than among those without (P < 0.001). Mortality risk factors were post-LT infection with multidrug-resistant bacteria, LT performed because of fulminant hepatitis, retransplantation, prolonged cold ischemia, longer LT surgical time, and pre-LT CRAB acquisition, the last showing a trend toward significance (P = 0.08). In conclusion, pre-LT CRAB acquisition appears to increase the risk of post-LT CRAB infection, which has a negative impact on recipient survival. Liver Transplantation 22 615-626 2016 AASLD.

The evolving threat of carbapenem‐resistant infections after liver transplantation: The case of A cinetobacter baumannii

“…The high mortality rate (40%-70%) associated with post-LT carbapenemresistant Klebsiella pneumoniae (CRKP) infections is a sobering example of the impact of MDR infection in this population. (2,3) In this issue of Liver Transplantation, Freire et al (4) provide compelling evidence that an additional organism, carbapenem-resistant Acinetobacter baumannii (CRAB), is also associated with very high morbidity and mortality after LT. In a prospective 2-year cohort study, the authors routinely surveyed colonization with A. baumannii at 3 body sites (rectum, throat, and axilla) immediately prior to LT and weekly thereafter until hospital discharge.…”

“…These limitations notwithstanding, this prospective investigation of a large Brazilian LT population with a protocol-driven longitudinal sampling of multiple body sites in the pre-and post-LT period, with an additional PFGE analysis of the samples is an impressive accomplishment by Freire et al (4) Although poor outcomes in solid organ transplant recipients with CRAB infection have been described before in multiple parts of the world including Taiwan, China, South Korea, Turkey, Poland, Spain, and the United States, (7,8) few studies have been as extensive or as detailed as the current one. In the end, one can conclude from this study that CRAB colonization and infection in LT recipients is a potentially serious development and prevention measures, both hospital-wide and specific to LT units, need to be in place to effectively prevent this complication.…”

<p>Prevalence, Risk Factors And Treatment Of The Most Common Gram-Negative Bacterial Infections In Liver Transplant Recipients: A Review</p>

“…39 Also, prolonged cold ischemia, dialysis after liver Tx, liver Tx due to fulminant hepatitis, colonization with carbapenemresistant A. baumannii (CRAB) before Tx, length of ICU stay following Tx, central venous catheter use and previous use of any antibiotic and, specifically, carbapenem were introduced as risk factors for developing CRAB in previous studies. 37,40,41…”

Transplanting patients with active bacterial infection

“…For example, post‐LT infection with a highly resistant organism such as carbapenem‐resistant Klebsiella pneumoniae (CRKP) may be among the strongest clinical predictors of post‐LT mortality, with an adjusted hazard ratio of 6.92 in the largest series to date . Similarly, pre‐LT infections with carbapenem‐resistant Acinetobacter baumannii (CRAB) are associated with post‐LT infections with the same organism, which are in turn associated with poor outcomes . There is a growing literature on the use of active screening for MDR colonization to guide prophylaxis and also debate whether patients colonized with these microbes should be considered eligible for LT .…”

“…17 Similarly, pre-LT infections with carbapenem-resistant Acinetobacter baumannii (CRAB) are associated with post-LT infections with the same organism, which are in turn associated with poor outcomes. 18 There is a growing literature on the use of active screening for MDR colonization to guide prophylaxis and also debate whether patients colonized with these microbes should be considered eligible for LT. 19 LT during active MDR infection, especially CRKP and CRAB, which require the most toxic antibiotic regimens, may not be advisable in our opinion.…”